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1.
Am J Obstet Gynecol MFM ; 4(1): 100503, 2021 Oct 17.
Artigo em Inglês | MEDLINE | ID: mdl-34666197

RESUMO

OBJECTIVE: Despite the knowledge that bed rest does not reduce the risk of preterm birth (PTB), it continues to be recommended by many providers worldwide. This is because there are no quantitative data assessing the relationship between PTB and physical activity in pregnancy.1-3 We designed a prospective cohort study using a Fitbit activity tracker to quantitatively explore the association between baseline physical activity in pregnancy in steps/day and the risk of PTB (<37 weeks). STUDY DESIGN: This was a prospective cohort study assessing the association between the risk of PTB and physical activity in healthy nulliparous women from 10 to 24 weeks to delivery. The physical activity (San Francisco, California) was measured from the time of entry into the study until the day before admission for delivery using the Fitbit Flex 2. The participants wore the faceless device 24/7 without modifying their activity. The primary exposure was steps/day in low- (<5000 steps/d) and high-level (≥5000 steps/d) activity groups. The primary outcome was the rate of PTB (<37 weeks). An additional unplanned secondary analysis was performed using a 3500 steps/d cutoff. The secondary outcomes included peripartum complications and median steps/day in term vs preterm groups. Adjusted analyses were performed to account for possible confounders. RESULTS: A total of 134 women were enrolled, of which 25 (19%) and 109 (81%) were in the low- and high-level activity groups, respectively. Overall, 11 (8.2%) women delivered preterm. The high-level activity group was older, partnered, employed, and had a higher education level. The PTB did not differ between the groups (adjusted risk ratio, 0.99; 95% confidence interval [CI], 0.99-1.00) (Table). There was no difference in the median steps/d between preterm and term deliveries (7767 interquartile range, [5188-10,387] vs 6986 [5412-8528]); percentile difference, -442; (95% CI, -2233 to 1507) steps. Using a 3500 steps/d cutoff, there was a 75% reduction in the PTB risk (29% vs 7%, respectively; risk ratio, 0.25; 95% CI, 0.05-2.35) (Table). CONCLUSION: This prospective study of nulliparous women showed no difference in the risk of PTB between low- vs high-activity groups using a cutoff of 5000 steps/d. The gestational age at delivery was similar between the groups. No significant difference in the number of steps/d was observed between women who delivered preterm compared with term. The women who were prescribed activity restriction (AR) had a marked reduction in their median number of steps/d after AR was prescribed. However, their median number of steps per day (>5000) reflected that they remained active despite this instruction. An additional analysis using 3500 steps/d as a cutoff for exposure groups showed a significantly increased risk of PTB in the <3500 steps/d group than the ≥3500 steps/d group. It is therefore plausible that activity levels <3500 steps/d are associated with an increased risk of PTB.

3.
Eur J Obstet Gynecol Reprod Biol ; 266: 23-30, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34560330

RESUMO

OBJECTIVE: Our objective was to examine if US obstetrician-gynecologists (OBGYNs) practice outside of evidenced-based guidelines and use a combination of interventions to prevent spontaneous preterm birth (sPTB). STUDY DESIGN: An electronic survey was distributed to members of the Pregnancy-Related Care Research Network (PRCRN), and also to members of the Society of Maternal-Fetal Medicine (SMFM). The survey consisted of questions regarding physician demographics, and the use of interventions to prevent sPTB in women with 1) a prior sPTB, 2) an incidental short cervix (no prior sPTB), and 3) a history of cervical insufficiency. RESULTS: The PRCRN response rate was 58.6% (283/483) with an additional 143 responses from SMFM members. Among PRCRN responders, 82.7% were general OBGYNs and 17.3% were Maternal-Fetal Medicine subspecialists. Respondents were from all geographic regions of the country; most practiced in a group private practice (42.6%) or academic institution (31.4%). In women with prior sPTB, 45.2% of respondents would consider combination therapy, most commonly weekly intramuscular progesterone (IM-P) and serial cervical length (CL) measurements. If the patient then develops a short cervix, 33.7% would consider adding an ultrasound-indicated cerclage. In women with an incidental short cervix, 66.8% of respondents were likely to recommend single therapy with daily vaginal progesterone (VP). If a patient developed an incidentally dilated cervix, 40.8% of PRCRN respondents would recommend dual therapy, most commonly cerclage + VP, whereas 64.3% of SMFM respondents were likely to continue with VP only. In women with a history of cervical insufficiency, 47% of PRCRN respondents indicated they would consider a combination of IM-P, history-indicated cerclage and serial CL measurements. CONCLUSION: Although not currently supported by evidence-based medicine, combination therapy is commonly being used by U.S. OBGYNs to prevent sPTB in women with risk factors such as prior sPTB, short or dilated cervix or more than one of these risks.


Assuntos
Cerclagem Cervical , Nascimento Prematuro , Administração Intravaginal , Medida do Comprimento Cervical , Colo do Útero/diagnóstico por imagem , Feminino , Humanos , Recém-Nascido , Gravidez , Nascimento Prematuro/prevenção & controle , Progesterona
4.
BMJ Open ; 11(1): e043052, 2021 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-33414149

RESUMO

INTRODUCTION: Cardiovascular and cerebrovascular diseases (CCVDs) are the leading cause of maternal mortality in the first year after delivery. Women whose pregnancies were complicated by pre-eclampsia are at particularly high risk for adverse events. In addition, women with a history of pre-eclampsia have higher risk of CCVD later in life. The physiological mechanisms that contribute to increased CCVD risk in these women are not well understood, and the optimal clinical pathways for postpartum CCVD risk reduction are not yet defined. METHODS AND ANALYSIS: The Motherhealth Study (MHS) is a prospective cohort study at Columbia University Irving Medical Center (CUIMC), a quaternary care academic medical centre serving a multiethnic population in New York City. MHS began recruitment on 28 September 2018 and will enrol 60 women diagnosed with pre-eclampsia with severe features in the antepartum or postpartum period, and 40 normotensive pregnant women as a comparison cohort. Clinical data, biospecimens and measures of vascular function will be collected from all participants at the time of enrolment. Women in the pre-eclampsia group will complete an additional three postpartum study visits over 12-24 months. Visits will include additional detailed cardiovascular and cerebrovascular phenotyping. As this is an exploratory, observational pilot study, only descriptive statistics are planned. Data will be used to inform power calculations for future planned interventional studies. ETHICS AND DISSEMINATION: The CUIMC Institutional Review Board approved this study prior to initiation of recruitment. All participants signed informed consent prior to enrolment. Results will be disseminated to the clinical and research community, along with the public, on completion of analyses. Data will be shared on reasonable request.


Assuntos
Pré-Eclâmpsia , Pressão Sanguínea , Estudos de Coortes , Feminino , Humanos , Cidade de Nova Iorque , Estudos Observacionais como Assunto , Pré-Eclâmpsia/epidemiologia , Gravidez , Estudos Prospectivos
5.
Clin Perinatol ; 47(4): 817-833, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33153664

RESUMO

"Pregnancy-induced hypertension" (HDP) describes a spectrum of disorders, including gestational hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. Each of these disease processes can progress to a more pathologic case with worsening hypertensive disease, end-organ damage, and concerning clinical sequelae. Risk factors for HDP include nulliparity, a prior pregnancy complicated by hypertension, and obesity. Close blood pressure monitoring, serologic and urine testing, and prompt clinical follow-up remain the gold standard for antenatal diagnosis and surveillance. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multidisciplinary team-based approach, and referral to an experienced provider for cases with advanced pathology.

6.
J Matern Fetal Neonatal Med ; 32(16): 2680-2687, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29478359

RESUMO

OBJECTIVE: The objective of this study was to characterize morbidity, acuity, and maternal risks associated with preeclampsia across hospitals with varying obstetric volumes. METHODS: This retrospective cohort analysis used a large administrative data source, the Perspective database, to characterize the risk for preeclampsia from 2006 to 2015. Hospitals were classified as having either low (≤1000), moderate (1001-2000), or high (≥2000) delivery volume. The primary outcomes included preeclampsia, antihypertensive administration, comorbidity, and related severe maternal morbidity. Severe maternal morbidity was estimated using criteria from the Centers for Disease Control and Prevention. Comorbidity was estimated using an obstetric comorbidity index. Univariable comparisons were made with Chi-squared test. Adjusted log linear regression models were fit to assess factors associated with severe morbidity with risk ratios with 95% confidence intervals as the measures of effect. Population weights were applied to create national estimates. RESULTS: Of 36,985,729 deliveries included, 1,414,484 (3.8%) had a diagnosis of preeclampsia. Of these, 779,511 (2.1%) had mild, 171,109 (0.5%) superimposed, and 463,864 (1.3%) severe preeclampsia. The prevalence of mild, superimposed, and severe preeclampsia each increased over the study period with severe and superimposed preeclampsia as opposed to mild preeclampsia increasing the most proportionately (53.2 and 102.5 versus 10.8%, respectively). The use of antihypertensives used to treat severe range hypertension increased with use of intravenous labetalol increasing 31.5%, 43.2%, and 36.1% at low-, medium-, and high-volume hospitals. Comorbid risk also increased across hospital volume settings as did risk for severe maternal morbidity. CONCLUSIONS: Preeclampsia is increasing across obstetric care settings with preeclamptic patients demonstrating increasing comorbid risk, increased risk for severe morbidity, and more frequent need for treatment of acute hypertension.


Assuntos
Parto Obstétrico/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Pré-Eclâmpsia/epidemiologia , Adolescente , Adulto , Comorbidade , Feminino , Humanos , Incidência , Pré-Eclâmpsia/classificação , Gravidez , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
7.
Obstet Gynecol ; 132(2): 404-413, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29995723

RESUMO

OBJECTIVE: To clarify how race is associated with adverse maternal outcomes and risk for women aged 40 years or older. METHODS: This retrospective cohort study used the Nationwide Inpatient Sample for the years 1998-2014. Women aged 40-54 years were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. Temporal trends in severe maternal morbidity and overall comorbid risk by race in women aged 40 years or older were evaluated as were common pregnancy complications including preeclampsia, gestational diabetes, and cesarean delivery. Adjusted models were created to assess factors associated with severe morbidity. RESULTS: A total of 1,724,694 deliveries were included in this analysis. Severe maternal morbidity increased over the study period from 1.6% in 1998-2000 to 3.0% from 2013 to 2014. Black women had the highest rates of severe morbidity at both the beginning (2.4% in 1998-2000) and the end (4.9% in 2013-2014) of the study period. During this same period, comorbid risk based on medical conditions and other factors increased overall and individually by race. Black women also experienced the absolute largest increase from 1998-2003 to 2010-2014 in risk for acute renal failure, disseminated intravascular coagulation, transfusion, and hysterectomy. Pregnancy complications including preeclampsia, cesarean delivery, and gestational diabetes were more common at the end compared with the beginning of the study for black, white, and Hispanic women. The adjusted risk ratio for overall severe morbidity for black compared with white race was 1.81 (95% CI 1.76-1.87). Black women had a substantially higher risk of death than white women (risk ratio 4.71, 95% CI 3.36-6.61), and Hispanic women had more than twice the risk of death (risk ratio 2.13, 95% CI 1.48-3.07) as white women. CONCLUSION: Although black women older than 40 years were at increased risk for adverse outcomes and severe morbidity, this differential was of smaller magnitude than reported mortality risk.


Assuntos
Grupos Étnicos , Complicações na Gravidez/etnologia , Adulto , Fatores Etários , Bases de Dados Factuais , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Complicações na Gravidez/etiologia , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia
8.
Obstet Gynecol ; 132(1): 185-192, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29889742

RESUMO

OBJECTIVE: To estimate whether the diagnosis of asthma is associated with the use of specific uterotonic and antihypertensive medications during delivery hospitalizations. METHODS: We used Perspective, an administrative database, to determine whether women hospitalized for delivery complicated by postpartum hemorrhage or preeclampsia received uterotonics and antihypertensive medications differentially based on the absence or presence of asthma from 2006 to 2015. Given that carboprost and intravenous (IV) labetalol may be associated with asthma exacerbation, adjusted models for receipt of these medications were created with adjusted risk ratios with 95% CIs as measures of effect. Risk for status asthmaticus based on receipt of carboprost and IV labetalol was analyzed. RESULTS: Over the study period, a total of 5,691,178 women were analyzed, of whom 239,915 (4.2%) had preeclampsia and 139,841 postpartum hemorrhage (2.5%). Carboprost was used less frequently in patients with asthma compared with patients with no asthma (11.4% vs 18.0%) in comparison with IV labetalol, which was used more commonly when a diagnosis of asthma was present (18.5% vs 16.7%). In unadjusted analysis, the presence of asthma was associated with a 37% decrease in likelihood of carboprost use and an 11% increase in likelihood of labetalol use. In adjusted analysis, the presence of asthma was associated with a 32% decrease in likelihood of carboprost use (adjusted risk ratio 0.68, 95% CI 0.62-0.74) compared with a 7% decrease in labetalol use (adjusted risk ratio 0.93, 95% CI 0.90-0.97). Risk for status asthmaticus was significantly increased with use of IV labetalol compared with other antihypertensive medications (6.5 vs 1.7/1,000 delivery hospitalizations, P<.01). CONCLUSION: There may be an opportunity to reduce use of ß-blockers and carboprost among patients with asthma. Given their association with status asthmaticus, these drugs should be used cautiously in women with asthma.


Assuntos
Anti-Hipertensivos/efeitos adversos , Asma/tratamento farmacológico , Parto Obstétrico/efeitos adversos , Ocitócicos/efeitos adversos , Complicações na Gravidez/tratamento farmacológico , Adulto , Asma/induzido quimicamente , Carboprosta/efeitos adversos , Contraindicações de Medicamentos , Bases de Dados Factuais , Quimioterapia Combinada/efeitos adversos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Labetalol/efeitos adversos , Razão de Chances , Ocitocina/efeitos adversos , Hemorragia Pós-Parto/induzido quimicamente , Hemorragia Pós-Parto/tratamento farmacológico , Pré-Eclâmpsia/tratamento farmacológico , Gravidez
9.
Clin Perinatol ; 45(2): 181-198, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29747882

RESUMO

Antenatal corticosteroids remain one of the crucial interventions in those at risk for imminent preterm birth. Therapeutic benefits include reducing major complications of prematurity such as respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis, as well as an overall decrease in neonatal deaths. Optimal reductions in neonatal morbidity and mortality require a thoughtful review of the timing of administration. In addition, a thorough understanding is required of which patients maximally benefit from this intervention in the management and counseling of those at risk for preterm birth.


Assuntos
Corticosteroides/uso terapêutico , Mortalidade Infantil , Nascimento Prematuro/prevenção & controle , Cuidado Pré-Natal/métodos , Síndrome do Desconforto Respiratório do Recém-Nascido/prevenção & controle , Esquema de Medicação , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Doenças do Prematuro/prevenção & controle , Masculino , Segurança do Paciente , Seleção de Pacientes , Gravidez , Prognóstico , Estados Unidos
10.
J Pediatr Orthop ; 31(3): 284-92, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21415688

RESUMO

BACKGROUND: Orthopaedic intervention can have a wide range of functional and psychosocial effects on children with neuromuscular disease (NMD). In the multihandicapped child (Gross Motor Classification System IV/V), functional status, pain, psychosocial function, and health-related quality of life also have effects on the families of these child. The purpose of this study is to report the development and initial validation of an outcomes instrument specifically designed to assess the caregiver impact experienced by parents raising severely affected NMD children: the Assessment of Caregiver Experience with Neuromuscular Disease (ACEND). METHODS: In the first part of this prospective study, 61 children with NMD and their parents were administered a range of earlier validated pediatric health measures. A framework technique was used to select the most appropriate and relevant subset of questions from this large set. Sensitivity analyses guided the development of a master question list measuring caregiver impact, excluding items with low relevance, and modifying unclear questions. In the second part of the study, the ACEND was administered to the caregivers of 46 children with moderate-to-severe NMD. Statistical analyses were conducted to determine validity of the instrument. RESULTS: The resulting ACEND instrument included 2 domains, 7 subdomains, and 41 items. Domain 1, examining physical impact, includes 4 subdomains: feeding/grooming/dressing (6 items), sitting/play (5 items), transfers (5 items), and mobility (7 items). Domain 2, which examines general caregiver impact, included 3 subdomains: time (4 items), emotion (9 items), and finance (5 items). Mean overall relevance rating was 6.21 ± 0.37 and clarity rating was 6.68 ± 0.52 (scale 0 to 7). Multiple floor effects in patients with GMFCS V and ceiling effects in patients with GMFCS III were identified almost exclusively in motor-based items. Virtually no floor or ceiling effects were identified in the time, emotion or finance domains across GMFCS level. CONCLUSIONS: The initial validation demonstrated that ACEND is a valid, disease-specific measure to quantify experience on caregivers of children with NMD. Larger groups of patients across NMD disease type are currently being tested to strengthen validity findings. Additionally, the ACEND is now being administered before and after orthopaedic interventions to determine responsiveness, which is critical to health outcomes research. LEVEL OF EVIDENCE/RELEVANCE: IIc.


Assuntos
Cuidadores/psicologia , Doenças Neuromusculares/terapia , Procedimentos Ortopédicos/métodos , Pais/psicologia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Doenças Neuromusculares/fisiopatologia , Estudos Prospectivos , Qualidade de Vida , Índice de Gravidade de Doença , Inquéritos e Questionários , Resultado do Tratamento
11.
J Bone Joint Surg Am ; 92(1): 64-71, 2010 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-20048097

RESUMO

BACKGROUND: Spinal cord monitoring is now considered standard care during surgery for spinal deformity. Combined somatosensory and motor evoked potential monitoring allows the detection of early spinal cord dysfunction in most patients. The purpose of the current study was to identify clinical factors that increase the risk of intraoperative electrophysical changes and to provide management recommendations. METHODS: The records of 162 consecutive patients who underwent surgery for the treatment of spinal deformity at a tertiary referral center were reviewed. Electrophysical monitoring of these patients was considered to have been successful if reproducible signals had been obtained. Relevant electrophysical changes included a reduction, as compared with baseline, of >50% in the amplitude of the somatosensory evoked potentials; an increase, as compared with baseline, of >10% in the latency of the somatosensory evoked potentials; a loss of motor evoked potentials; and an abrupt decrease of >75% in the motor evoked potentials. RESULTS: One hundred and fifty-one (93%) of the 162 patients were monitored successfully. Four of the eleven patients with unsuccessful monitoring had neuromuscular scoliosis. Twelve of the 151 successfully monitored patients had a true electrophysical event, and two of them were found to have new postoperative neurologic deficits that represented a change from the findings of their preoperative neurologic examination. The determined causes of these electrophysical events included curve correction in eight patients, hypotension in two, direct cord trauma in one, and malposition of a pedicle screw in one. The patients with a true electrophysical event had a significantly higher rate of neurologic events than did the patients who did not have a true electrophysical event (p < 0.001). The rate of true electrophysical events was significantly higher in the patients with cardiopulmonary comorbidities than it was in the patients with no comorbidities (p = 0.011). CONCLUSIONS: Combined somatosensory and motor evoked potential monitoring effectively prevents neurologic injury in most children undergoing surgery for spinal deformity. Despite the potential for false-positive results, we recommend setting a low threshold for defining relevant electrophysical changes. Rapid intervention can reverse these changes and avoid potentially serious neurologic complications. Patients with cardiopulmonary comorbidities may be at a higher risk for having relevant electrophysical events.


Assuntos
Eletrodiagnóstico , Traumatismos da Medula Espinal/prevenção & controle , Curvaturas da Coluna Vertebral/cirurgia , Coluna Vertebral/anormalidades , Coluna Vertebral/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Potencial Evocado Motor , Potenciais Somatossensoriais Evocados , Feminino , Humanos , Cifose/cirurgia , Masculino , Monitorização Intraoperatória , Estudos Retrospectivos , Fatores de Risco , Escoliose/cirurgia , Traumatismos da Medula Espinal/diagnóstico , Espondilolistese/cirurgia , Adulto Jovem
12.
Spine (Phila Pa 1976) ; 33(11): 1242-9, 2008 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-18469699

RESUMO

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study is to evaluate pulmonary function and quality of life (QOL) in children treated with early spinal fusion for progressive congenital scoliosis. SUMMARY OF BACKGROUND DATA: The relationships between radiographic measures, pulmonary function tests (PFT), and QOL were examined. METHODS.: Twenty-one patients with congenital scoliosis treated with early spinal fusion were evaluated using radiographs, PFT, and the Child Health Questionnaire (CHQ) at 12.6 +/- 3.5 years. They were 6.9 +/- 2.3 years postdefinitive fusion, which occurred at 4.9 +/- 3.1 year of age. The cohort was also divided in two groups, "thoracic fusion" (apex above the thoracolumbar T-L junction) and "nonthoracic fusion" (below T-L junction). RESULTS: Forced vital capacity, forced expiratory volume (FEV1), vital capacity (P < 0.0001), and total lung capacity (P = 0.017) were significantly lower compared with healthy children. CHQ scores were significantly lower than in healthy children in physical function (P = 0.036), general health (P = 0.007), physical summary (P = 0.026), and parental impact/emotional (P = 0.01). Correlation analysis showed that the degrees of thoracic curves were negatively correlated with FEV1 (P < 0.05), family activities, role/social physical (P < 0.05), and physical summary (P < 0.01). The degree of kyphosis was negatively correlated with Self-Esteem (P < 0.01). Patients who had thoracic fusions had shorter spinal height (P = 0.049), lower forced vital capacity (P = 0.004), FEV (P = 0.012), vital capacity (P = 0.031), and reported more pain (P = 0.033) than nonthoracic fused. CONCLUSION: Compared with healthy peers, congenital scoliosis patients treated with early spinal fusion have worse PFT and QOL scores at 6.9 years follow up. Patients with thoracic fusions had shorter spines, worse pulmonary function, and more pain than nonthoracic fused. The results may support alternatives to early spinal fusion such as growing rods, epiphysiodesis, and distraction thoracoplasty. Current efforts are underway to compare outcomes of this study to those of other treatments.


Assuntos
Pulmão/fisiologia , Qualidade de Vida , Escoliose/diagnóstico por imagem , Escoliose/cirurgia , Fusão Vertebral , Adolescente , Adulto , Criança , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Qualidade de Vida/psicologia , Radiografia , Testes de Função Respiratória/tendências , Estudos Retrospectivos , Escoliose/psicologia , Fusão Vertebral/tendências , Resultado do Tratamento
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